Is Involuntary Hold for Psychiatric Patients the Only Answer?

Eleanor (not her real name) talked to me at length about her experience as a patient who had been committed to a psychiatric unit. Eleanor came to the emergency department in distress. In fact, she was screaming inconsolably when a physician gave her an injection of a sedating medication and filled out a “5150,” the California jargon for an involuntary hold. Eleanor’s stay on the unit lasted three weeks. During that time, she was repeatedly held down by security guards and injected with medications, and she spent a good deal of time in a seclusion room where she felt she was running out of oxygen. She crouched by the bottom of the door, trying to suck in air, all the while convinced that the staff were trying to kill her. It was a traumatic experience for Eleanor; to this day, she finds it difficult to ride in a car with the windows up, and years after her hospitalization, she continued to visit my psychiatry blog as part of an effort to process an experience she wanted never to repeat, one she readily called traumatizing.

Doorway to Psychiatric Care

The emergency department is the doorway to involuntary psychiatric care, and most emergency departments don’t have psychiatrists on-site. The most crucial and controversial decision in psychiatry often falls on the shoulders of an emergency physician, with or without the help of a mental health professional. Patients are involuntarily committed because they are acutely suicidal, acutely psychotic, or both. Someone is worried they might be dangerous.

The forces in play here are considerable. We have patients, who may be too impaired to make decisions or even see that they are ill and who should ideally have the right to autonomy over their medical decisions. We have society, which may worry that people with mental illness pose a danger to others. We have the families, who watch a loved one suffer and miss the wonderful opportunities that life has to offer but who may have their own agendas for wanting a family member to be in the hospital. We have the doctor, who wants to do right by patients while simultaneously serving as the gatekeeper for resources (that rare psychiatric bed) and worrying about the malpractice implications of a bad outcome. We have the taxpayer, who pays for lost productivity, disability benefits, and institutionalization of these patients. Finally, we have the insurer, who wants to pay for as little as possible. All of these agencies are quietly in the background whenever a decision is made to involuntarily hospitalize a patient (or not).

The most crucial and controversial decision in psychiatry often falls on the shoulders of an emergency physician, with or without the help of a mental health professional.

If doctors in the emergency department begin with the idea that forced care is a good thing—that it helps people get well at times when they may be too sick to recognize that they are ill, and that treatment enables patients to stay housed, working, connected to their loved ones, and out of jail and institutions—then they do it a lot, sometimes with a “better safe than sorry” approach. However, if doctors start off with the assumption that forced care is potentially traumatizing in a way that leaves some patients with years of distress, then the threshold for committing patients to involuntary treatment is significantly altered, and involuntary hospitalization gets viewed as a last resort.

5 Responses to “Is Involuntary Hold for Psychiatric Patients the Only Answer?”

While this is a thoughtful and compelling article, I find it important to note that it is a patient-centric piece without the balance of the health system/physician/staff/society perspective. In short, people present in crisis and the emergency department is often the only place to go. There are vanishingly few psychiatric emergency departments and, in my experience (multiple east coast states), voluntary services have limited availability during business hours and none for new patients off hours. Therapists and psychiatrists aren’t available (generally) to discuss their patients so emergency physicians are left in our usual predicament: limited information, questionable followup and pressure to keep the department moving. Let a patient walk out and they commit suicide — good luck defending that decision.

Imagine a better world: crisis workers who had the time to talk to patients, functional secure assessment areas that could accommodate patients safely for extended observation, and hospitals that acknowledged the importance of mental health patients and could provide resources to accomplish this. Oh, while I’m on my soap box – insurance companies actually paying reasonable rates to make this all work and not denying visits after the fact based on the outcome rather than the presentation…

I totally agree with Dr. Miller that kindness and offering comfort and even food to our psych pts in the ER forms a
bond of confidence to help in the healing process before the mental health team sees the patient.

Another article that talks about general concepts without addressing the very difficult reality surrounding these patients. I agree these patients have difficult and sometimes traumatizing emergency department experiences. I agree that we should be nice to them and try and deescalate circumstances were possible. The reality however is that frequently we cannot deescalate and the patient is already out of control. The disconnect between reality and concept is starkly apparent in Dr. Miller statement about not using force to adhere to policy. Specifically she mentions admission lab work. Anyone who has experience in emergency department is aware of the duck,bob and weave mentality that exists. Any excuse to delay specialty consultation and evaluation. In many cases the very specialist this patient most needs, mental health, refuses to evaluate the patient until a urine drug screen and alcohol level is available. In order to achieve expedited and critically needed care, sometimes force is necessary to “adhere to policy”. These patients are a victim of limited resources, limited time, and no one taking ownership of their issues. Unfortunately until needed dollars are committed to mental health, they will continue to languish for days in the emergency department “awaiting crisis disposition”.

In my area (Las Vegas) a “voluntary hold” is not an option. There are no psychiatrists available to the ERs. Patients placed on a hold will be visited in the subsequent 72 hours by a social worker sent by the agency contracted with the patient’s insurance plan or the county mental health organization if the patient is unfunded. These social workers then arrange for the patient to be held in the ED longer, sent to a psychiatric facility or they compel the EP to discharge them. The psychiatric social workers will not see a patient who is not on a legal hold. They will not see a “voluntary” patient. They are our only resource. Less severe patients must frequently choose if they wish to be placed on a hold or attempt to navigate the outpatient mental health maze on their own. I have no other options to give them.